MEDICARE: MS. IRIS DENISE PHILLIPS-PULLIAM LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LC301398	DC

General Provider Information

NPI Number	:	1174805089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. IRIS DENISE PHILLIPS-PULLIAM LICSW

Provider Business Mailing Address
First Line	:	6700 COOLRIDGE RD
Second Line	:
City	:	TEMPLE HILLS
State	:	MD
Zip	:	20748-2704
Country	:	US
Telephone Number	:	240-472-0780
Fax Number	:

Provider Business Practice Location Address
First Line	:	6700 COOLRIDGE RD
Second Line	:
City	:	TEMPLE HILLS
State	:	MD
Zip	:	20748-2704
Country	:	US
Telephone Number	:	240-472-0780
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2011
Last Update Date	:	09/16/2011

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